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Accidential Bowel Leakage (ABL)

What is accidental bowel leakage (ABL)?
Accidental bowel leakage of stool means the inability to control the passage of stool or gas. Some people have mild trouble holding gas; while others have severe trouble holding stool. Accidental bowel leakage is a miserable problem that many people have trouble talking about. People are frequently embarrassed and afraid there is no help. However, treatment is available. Colorectal surgeons are specially trained physicians who frequently care for this problem.

How common is this problem?
One study showed that over 2% of the population suffers from accidental bowel leakage. More than 30% of nursing home patients have leakage. It affects women more than men, and it becomes more common as people age and their sphincter muscles lose tone.

What causes incontinence?
Normal control of the passage of stool depends on many factors. A problem in any of the following areas can contribute to lack of control. One factor is the time it takes for stool to pass through the bowel. If stool moves through the bowel too quickly, a person may not have warning and may have an accident. This happens most commonly to people with irritable bowel syndrome or inflammation of the bowel (colitis). The consistency of the stool is difficult for anyone to control. Anything that causes diarrhea, such as infection, inflammation, and food intolerance, can lead to incontinence.

Normally, the rectum will stretch to hold stool or gas entering it, giving the person time to make it to the bathroom. If the rectum is full of stool or an abnormal growth, it may not expand further to hold additional stool. If this happens, loose stool may leak out. To prevent leakage one must be able to tell that stool or gas is present in the rectum. People with neurological problems, such as a stroke, may have abnormal sensation in the rectum. They will not be able to sense that gas or stool has entered into the rectum and therefore have no warning to go to the bathroom.

The sphincter muscle, a circle of muscle around the anus (rectal opening), keeps the anus closed. It needs to function properly in several ways for adequate control. It needs to hold the anus closed at rest and squeeze to tighten the anus when stool or gas enter the rectum. As people age, the muscle gradually loses strength. The sphincter muscle can also be injured during childbirth or during rectal surgery. If injury is recognized and repaired, the muscle usually heals properly. If it does not, there may be a gap in the circle of the muscle so it is unable to close correctly. For some people this gap is small and only becomes a problem when the muscle weakens with age. Two nerves stimulate the sphincter muscle. If the nerves are injured, the sphincter muscle may become weak. The nerves may be injured through stretching during pregnancy or childbirth or from excessive straining to move one’s bowels. Rectal prolapse, tissue that repeatedly comes out through the anus, can also stretch or injure the nerve. In these situations, the muscle is intact but does not work properly, resulting in incontinence.

What tests are available?
First, the doctor will ask questions about your symptoms, bowel habits, and other medical problems. You will then be examined with particular attention paid to the sphincter muscle, rectum, and lower colon. At this point, the doctor may know the cause of the accidental bowel leakage. If not, you may need to have some additional tests at our Pelvic Floor Center®. For one of those tests (manometry), a catheter is placed into the anus to record pressures as patients tighten and relax the sphincter muscle. Another test may also be done to test for proper nerve function. An ultrasound probe inserted into the anus can provide a picture of the muscles, which would show any area of injury. You may need an x-ray to check for rectal prolapse.

How is incontinence treated?

If present, the underlying problems are corrected. If a medical illness, such as inflammation of the bowel, infection, or irritable bowel syndrome, is causing the accidental bowel leakage, medication may be prescribed.

Diarrhea and constipation are treated with dietary changes, usually emphasizing a high-fiber diet. If accidental bowel leakage continues despite these changes, the treatment depends on the cause.

Accidental bowel leakage caused by injury to the sphincter muscles may require surgery. The muscles and nerves will be tested before surgery to help predict the success of the surgery. If the muscle is intact but functions poorly, dietary changes may help.

Biofeedback or pelvic floor muscle training may also be recommended. This program teaches people to consciously identify and exercise their pelvic floor muscles.

New methods of replacing the sphincter muscle are currently being investigated and hold promise for the future. Finally, for patients with severe accidental bowel leakage, a colostomy greatly improves their lifestyle.

If the underlying cause of accidental bowel leakage cannot be completely corrected, measures can be taken to make the problem more manageable. Regular bowel movements help to keep the rectum empty, which decreases the chance of accidental leakage. A high-fiber diet and/or fiber supplements will usually improve constipation. Fiber also helps people with diarrhea by absorbing the water and making stool more formed. The doctor may also recommend medication to control diarrhea.

Many people are concerned about leaving home because of accidental bowel leakage. Enemas or rectal irrigation can be used to empty the rectum and reduce the chance of leakage. Many patients find these useful prior to leaving home.

For people with accidental bowel leakage, one troubling aspect is the painful skin irritation that may occur. There are many methods for preventing or improving skin irritation, and the details should be discussed with your doctor. After cleansing, the skin should be gently dried. The general principle is to keep the skin as dry as possible. Many people use a hair dryer. A protective barrier cream is applied lightly and the skin is covered with rolled cotton gauze. This should be done if one needs to wear protective pad or garment. Many people find that carrying a kit with the necessary supplies reduces their anxiety about episodes that may occur away from home.

Patients with accidental bowel leakage are encouraged to speak with their doctors. Help is available.